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,.�. R`.``a. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
PROPERTY TAX BENEFITS '
State Form 43708(R191 7-25) Q...6,101,-\ shi..?1_, 'r(:`!w Prescribed by the Department of Local Government Finance
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
Instructions. To be filed in person or by mail with the county auditor of the county where the properly is located
Filing Date: Form must be completed, signed, and bled with the county auditor or postmarked by January 15 of the calendar year in
which the property taxes are first due and payable
See reverse side for additional instructions and qualifications
Type of Benefit Requested (Please check all that apply)
GOver 65 Credit Rover 65 Circuit Breaker Credit
Name of Applicant(owner or contract buyer) Telephone Number Email Address
( 8\11_,_ C-A--\ - Cis ‘ 00 , -
Is Appii the Sae Legal orEquifatllir wne • If No, What is Applicant's Exact Share or Interest? It Owned with Joint Tenant or Tenant in Common, Indicate with Whom
EYes ❑No
$1 Name on Record rs Different than Applicant. Indicate Below Do All Joint Tenants or Tenants in Common side on the Property?
Ekes ❑No
Name of Contract Seller Has Applicant Owned or Bought the Property Recorded Contract y
liar at Least One(1)Year before Claiming .
es ❑No
Address of Contract Seller (number and street, city, state, and ZIP code) Is the ProRerty in Question-
,
Real Property ❑ Mobile Home(IC 6-1.1-7)
Tta4ing District Key Number/Legal Description Record Number Page Number
1
1 --1H -CiQ-7 ,
Did Applicant qualify for the homestead stan6sird deduction in the preceding year (or was applicant marred at the time of death to
a deceased spouse who qualified for a homestead standard deduction for the individual's homestead property in the immediately IZIXeS ❑ No
preceding calendar year)and does Applicant qualify for the homestead standard deduction in the current year?
is the Applicant 65 Years of Age or More on December 31 of the Year Prior to the Year Taxes are First Due& Payable? BS ❑NO
Applicant's Date f Birth (neonth, day,year) l If Filed by a Surviving,Untamed Spouse,What Was the Spouse's Age at the Time of Death?
\) — r7 \-1 '-- c-- $1 V — 31c;Cd' (12 . ,
Source of Income Amount of Income
Adjusted Gross Income (AGI)of applicant, applicant and spouse,or applicant ,
and joint tenants or tenants in common, as applicable (For Over 65 Credit, AG! \ "�-� $may not exceed (1) $60,000 for i dividuals wino filed a single return, (2)570,000 for �C)\
`I
nxiivrduals who filed a pint return, or(3)$70,000 for individuals and al others that ,
share ownership as joint tenants or tenants in corrmon. For the Over 65 Crcud
Breaker Credit, AGI may not exceed:(1)$60,000 for individuals who flied a single ` ~ S
return;or(2)$70,000 for individuals who filed a pint return with the ndrvrcdua/'s t L64-4,1) ,
-
spouse.)(Beginning wiih i Pay 27, income amounts for the Circuit Breaker Credit are
annually adjusted.]See reverse for details. TOTAL $ r--- - -
WVe certify under penalty of perjury that the above and foregoing information is true and correct.
Signal e of Applica I Date (month, day, year)
7/Ct'Arl
Address of Ap ican (number and-,eel, city, stale, and ZIP
0 .k- 3. \ Q\A
icciNt 0 k -ki-er -\'‘ .
Signature of Authorized Representative _ ,-) — .-t. -- .Q .
Date (month, day, year)
Address of Authorized Representative (number and street, city, state, and ZIP code)
F ILED
Signature of County Auditor Date (month, day, year
`N �.\ 4- ,, (D - I --Q Q .
F E B 13 2026
N l' iti-- '
DISTRIBUTION: Original - County Auditor; File-Stamped Copy - Taxpayer
iz:��� C.,!/. Piril,0 �,
GIBSON COUNTY AUDITOR